JOURNAL READING

Management of Hypertension among Patients

with Coronary Heart Disease
Oladipupo Olafiranye, Ferdinand Zizi, Perry Brimah, Girardin Jean-louis, Amgad N.
Makaryus, Samy McFarlane and Gbenga Ogedegbe
SAGE-Hindawi Access to Research International Journal of Hypertension Volume 2011

PRESENTED BY :
Neneng Wulandari I11110049

LECTURER :
dr. Iqbal Lahmadi, Sp.PD

Department of Internal Medicine

Kartika Husada Hospital
Faculty of Medicine Tanjungpura University
Background
Hypertension is not only a major risk factor for
stroke and heart failure (HF), but more importantly
for coronary heart disease (CHD).
The report of the INTERHEART study involving 52
countries all over the world showed that
hypertension conferred a greater adjusted relative
risk of acute myocardial infarction than diabetes.
Among individuals aged 40 to 90 years, each 20/10
mm Hg rise in BP doubles the risk of fatal coronary
events.
 Background (cont...)
Hypertension accelerates the development and
progression of atherosclerosis, and sustained elevation
of BP can destabilize vascular lesions and precipitate
acute coronary events.
The goal of treating patients with hypertension and
CHD are to lower BP, reduce ischemia, and prevent CVS
events.
Discuss the treatment options and the goals of therapy
that are consistent with the recommendations of JNC 7
and American Heart Association (AHA) scientific
statement.
Link between
Hypertension
and Coronary
Heart Disease
Therapy for Hypertension in CHD
Hypertension in CHD

Beta- blockers
Non
Pharmacological
Therapy for

Treatment Calcium channel blockers

Nitrates
Pharmacological
Treatment Angiotensin-Converting Enzyme
inhibitors

Angiotensin-Receptor Blockers

Diuretics
Therapy for Hypertension in CHD

AHA guideline clarified this issue and recommended

the same target BP of 130/80 mm Hg as for other
high-risk population with caution in lowering the DBP
below 60 mmHg which may impair coronary
perfusion.
The goals to lower BP, reduce ischemia, and
prevent cardiovascular events and death.
Therapy for Hypertension in CHD
Nonpharmacological

Regular exercise is recommended in all

individuals with hypertension and CHD.

Lifestyle changes and adoption of

healthful behaviors are equally important
in the management of hypertension and
CHD.
Therapy for Hypertension in CHD
Beta blockers
Should begin with -blockers as first-line therapy
Relative contraindications hypotension, severe
bronchospastic lung disease, decompensated HF, sinus or
atrioventricular node dysfunction, and severe peripheral
vascular disease.
The cardioselective -blockers without intrinsic
sympathomimetic activity are generally preferred.

Study of Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT) and

the Conduit Artery Function Evaluation (CAFE), showed that
Atenolol was less effective in reducing systolic BP and cardiac
afterload than amlodipine.
Therapy for Hypertension in CHD
Calcium channel blocker
Long-acting dihydropyridines amlodipine, and nifedipine can be added to
the basic regimen if BP remains elevated or angina continues while on -
blocker therapy. Risk severe bradycardia or atrioventricular block.
Recommendation long acting dihidropyridine.
Nondihydropyridine agents, diltiazem and verapamil, can also be substituted
for -blocker when contraindications exist or side effects develop.

The Controlled-Onset Verapamil IN Cardiovascular Endpoint (CONVINCE) trial,

the NORdic DILtiazem (NORDIL) study, and the International Verapamil
SR/Trandolapril (INVEST) study showed that :
CCBs appear to be good substitutes for -blockers in the treatment of angina
in hypertensive patients.
Non dihidropyridine Should not be used in px with sistolic HF
Short acting dyhydropiridine should be avoided in acute MI, pulmonary
edema or LV dysfunction
Therapy for Hypertension in CHD
Nitrates
Indicated for acute relief of angina or treatment of chronic
angina which cannot be controlled with -blockers and CCBs.
Only to relieve angina, control BP, and manage pulmonary
congestion.

Individuals taking nitrates should be advised not to use

phosphodiesterase inhibitors such as sildenafil, as the combination
of both may cause severe hypotension.
Therapy for Hypertension in CHD
Angiotensin-Converting Enzyme inhibitors

Recommended for use in all patients after MI.

The European Trial on Reduction of Cardiac Events with Perindopril in
Stable Coronary Artery Disease (EUROPA) and Heart Outcome
Prevention Evaluation (HOPE) study, showed the cardioprotective
effect of ACE inhibitor in hypertensive CHD patients.
Prevention of Events with Angiotensin Converting Enzyme inhibition
(PEACE), involving stable CHD patients with normal or slightly reduced
ejection fraction raised question about the usefullness of ACE
inhibitors in low-risk CHD px with normal LV systolic function.

ACE inhibitors are indicated for all hypertensive patients with acute MI
who have no contraindications, especially if there is associated
depressed LV systolic function (LVEF < 40%)
Therapy for Hypertension in CHD
Angiotensin-Receptor Blockers
Indicated individuals who are ACE inhibitor intolerant or
allergic.
In the VALIANT study, the ARB, valsartan was as effective as
captopril in patients at high risk of CVS events after MI.
Valsartan Antihypertensive Long term Use Evaluation (VALUE)
trial, the ARB, valsartan, and CCB, amlodipine had similar
primary protection against CVS events.
Diuretics
The effectiveness of thiazide in controlling BP and preventing
CVS events has been demonstrated in several studies but their
use in the setting of acute MI is not encouraged and if at all
required, should be done with caution.
Conclusion
The target BP in hypertensive patients with CHD is
<130/80 mm Hg with caution in lowering the DBP below
60 mm Hg.

Treatment regimen should include -blocker, ACE

inhibitor, or ARB, most especially if there is LV systolic
dysfunction and/or diabetes mellitus, and possibly a
thiazide diuretic.

CCBs can be used as alternative to -blocker or added to

the basic regimen, and nitrates are useful for relieve of
ischemic pain.
Thank You...